WIC Immunization Screening and Referral

WIC Immunization Screening and Referral
Staff Training Guide Developed by The National WIC-Immunization Workgroup USDA/Food and Nutrition Service CDC/National Immunization Program National WIC Association American Academy of Pediatrics Association of State and Territorial Health Officials Association of Immunization Managers Every Child By Two OCTOBER 2002

Training Objectives This training will help you to:
Understand how vaccines can help prevent life-threatening diseases Understand the recommended childhood immunization schedule Relate the importance of immunizations to keeping WIC infants/children healthy and to WIC program goals Understand the the new USDA Immunization Screening and Referral policy and identify policy requirements Screen immunization records using an easy tool: “Easy IZ Guide” Talk to parents about their child’s immunization status Determine effective ways to refer patients to immunization services

Module 1 Communicable Diseases and Vaccines
Why Immunize Infants and Children? In this module we are going to discuss why it is important to immunize infants/children. Many of you may be young enough that you have never seen these diseases. But after the next 15 minutes you will know why we still vaccinate infants/children against them.

Not long ago, parents lived in fear of diseases we can now prevent
The vaccine became available in 1955; now no polio in the U.S.! Polio still exists in other parts of the world; easily imported In 1916, polio killed 6,000 people & paralyzed 27,000 Not long ago, parents lived in fear of diseases we can now prevent. How many of you remember getting polio vaccine on a sugar cube in a line at school? Does anyone have a relative that had polio? {Participants raise their hands and quickly discuss their experiences.} In 1916, polio killed 6,000 people & paralyzed 27,000 in the United States alone. As late as the 1950’s, parents refused to let their infants/children go to movies or go swimming for fear of catching the disease. Polio vaccine became available in 1955 and people clambered to get their infants/children vaccinated. Polio immediately started to disappear. Now there is no wild polio in the U.S. or the other countries of the Americas. Unfortunately, we can’t stop vaccinating yet because there is still polio in a few parts of the world and it could find its way back into this country.

Measles Today, many do not know measles can be serious
For every 1,000 infants/children who have measles: 50 get pneumonia 1 gets brain inflammation 1 or 2 die During the U.S. outbreak in there were Almost 56,000 cases 123 deaths It shocks a lot of people to learn that measles was once more dreaded than smallpox. Parents today may not realize how serious measles is. For every 1,000 infants/children who get measles: 50 get pneumonia 1 gets brain inflammation (encephalitis) 1 or 2 die even with modern medical care. Measles is completely preventable through vaccination. It is sad to think that in the richest country in the world we could still have an outbreak of measles. But that’s exactly what happened between 1989 and 1991. Almost 56,000 people got measles during those three years and 123 died. It was because of this measles epidemic that WIC began helping Immunization programs. CDC credits WIC with being instrumental in helping to stop the epidemic. Could another large-scale measles outbreak happen again?? It could, if we let immunization rates drop.

Vaccines Prevent Serious Childhood Diseases
Diphtheria Tetanus (lockjaw) Pertussis (whooping cough) Measles Mumps Rubella (German measles) Hib Pneumococcus Hepatitis B Hepatitis A Polio Varicella (chickenpox) Here is a list of the vaccines that are routinely recommended for infants/children. All of these vaccines can prevent serious diseases. {Note - in some areas, the speaker may not want to include hepatitis A.} Parents may not have heard of all these diseases, or know why vaccinating against them is so important.

Even chickenpox is a serious illness
Before the vaccine, almost everyone got chickenpox Six out of every 100,000 infants who get chickenpox die. Take chickenpox. A mild itchy rash that might make your child uncomfortable and miss school for a couple weeks. This picture tells a different story. Even chickenpox can be serious – not often, maybe, but why take a chance? Before varicella (chickenpox) vaccine, almost everyone got chickenpox. Usually, it is mild. But, did you know that out of every 100,000 infants who get chickenpox about 6 die? This baby got chickenpox at birth from her infected mother, and developed a severe skin infection. (She got proper treatment, and recovered.)

Vaccines Prevent Diseases that have no cure
Some diseases prevented by vaccines cannot be treated when a person gets the disease Tetanus can be prevented by vaccine, but there is no medication that cures tetanus disease Many diseases that can be prevented by vaccines cannot be treated if a person gets the disease. This makes vaccination even more important. For example, there is no antibiotic or other medication that can cure tetanus. A child who has not been vaccinated against tetanus and gets the disease has a one in ten chance of dying.

We have (almost) forgotten some diseases like diphtheria
During the 1920’s about 150,000 cases/year and 15,000 deaths occurred Now in the U.S. a few cases occur, but there are outbreaks in countries of former Soviet Union We have almost forgotten some childhood diseases - for example, diphtheria. The diphtheria bacteria produce a powerful poison that can cause serious complications such as heart failure or paralysis. In the 1920’s there were about 150,000 cases of diphtheria each year in the US and about 15,000 deaths. Now, thanks to the vaccine, there are only few cases a year. But in countries of the former Soviet Union there were 50,000 cases in This outbreak may have been due to a failure to keep ADULTS up to date on their vaccinations.

Complications from Hepatitis B infection can come later in life
Hepatitis B virus invades the liver causing cirrhosis and cancer Infected infants are at greatest risk for serious complications No cure In 1996, 4,000 to 5,000 deaths/year in US Sometimes, the serious consequences of a disease come 20 years after the disease starts. That’s the case, with hepatitis B infection. Even if “only” 400 people die each year directly from a hepatitis B infection, the virus continues to act in a slow way. Hepatitis B virus invades the liver and gradually, over twenty years, it can lead to liver cirrhosis (which is a breakdown of the liver) and cancer. This is how hepatitis B kills most of its victims. Infected infants are at greatest risk for serious complications. If a pregnant woman has hepatitis B, her baby has a 40% chance of being infected if it is not vaccinated at birth. There is NO CURE for hepatitis B. There is no antibiotic treatment. As of 1996, there were 4,000 to 5,000 deaths each year in US as a result of chronic hepatitis B and these can be prevented with hepatitis B vaccine.

Pertussis (whooping cough):
After 1-2 weeks of ‘cold’ symptoms, 1-6 weeks of coughing bouts Complications /1,000 cases: Pneumonia 95 Seizures 14 Brain inflammation 2 Death 2 Hospitalization This is a picture of an infant with pertussis, also known as whooping cough. An infant who can’t stop coughing, cannot eat or drink enough to stay alive. Pertussis starts like a regular cold. But after 1 or 2 weeks, coughing spasms begin, and might last 1 to 6 weeks. This is frightening to watch. The child coughs and coughs until there is no air it its lungs. When the child tries to suck in air, the airway is swollen, and as they try to breathe through the narrowed airway they make a whooping noise. As if this weren’t bad enough, pertussis also has complications. For every 1,000 infants/children with pertussis, 95 will develop pneumonia 14 will have seizures 2 will have brain inflammation (encephalitis) 2 will die Out of every 1,000 who get pertussis, 320 will need a hospital stay.

All Preventable Diseases in Children are Serious
Hib Pneumococcus Hepatitis B Hepatitis A Polio Varicella Diphtheria Tetanus (lockjaw) Pertussis (whooping cough) Measles Mumps Rubella (German measles) I’ve said that all the diseases we prevent in infants/children are serious -- but it’s worth repeating. We won’t go into each disease in depth, but let’s look at one of them again. The person in this picture has tetanus. If you don’t already have a healthy fear of tetanus, you should. It’s other name - lockjaw - says a lot – but the picture on this slide tells more. The disease causes the muscles to contract (note how his back is uncontrollably arched). In fact, muscle contractions can be so powerful that they break bones. Swallowing relies on muscles, too, so tetanus can also immobilize the muscles needed for eating and drinking. We could continue through the list and talk about each of these 12 diseases. The effects, consequences, and stories would be just as alarming as those for tetanus.

Vaccines are Key to Prevention
Measles, 1st Measles Vaccine Licensed in 1963 Up to now, I think I’ve made the point that the diseases we can prevent through vaccination were very common and very terrible. So - we vaccinate to prevent human suffering. But do the vaccines work? This graph gives you an idea of just how well they do work! It shows the number of measles cases (in thousands) that were reported in the US each year since As you can see, before we had a vaccine there were hundreds of thousands of cases each year. But as soon as first measles vaccine was licensed in boom -- the number of cases drops. Vaccines are a KEY to prevention.

Why not wait? Infants and young children are very vulnerable to infectious diseases An outbreak can be anywhere. Disease is a plane ride away. If there’s an outbreak, it may be too late. Some parents just don’t seem to have the time to get their children immunized on schedule…Why not let them wait? There are at least three good reasons. Infants and young children easily get infectious diseases. They are also the ones most likely to die from these diseases. You never know when a child will be exposed to someone carrying the disease germ or when an outbreak will occur here. In our modern world, even if disease levels here are low, disease is never more than a plane ride away. If there is an outbreak, it may be too late for vaccinations to work.

You don’t always know when a child has been exposed to a disease
You don’t always know when a child has been exposed to a disease. …Protect them first rather than wait! You don’t know if these infants/children have been exposed to a disease that can be prevented by a vaccine. Parents need to be reminded to protect their infants/children now. Don’t wait.

Immunizations are one of the most important ways to protect children!
Immunizations are one of THE most important ways parents can protect their infants/children.

Module 2 Recommended Childhood Immunization Schedule
To help you have a better understanding of ALL the shots that a child needs, we will go over the entire immunization schedule with you now. You do NOT have to memorize all this! In fact, using WIC’s new screening and referral requirement you will be looking at only one vaccine, not all of them. So for now just relax and follow along. The main goal is just to have the schedule make sense to you.

Vaccines that prevent disease
Diphtheria Tetanus (lockjaw) Pertussis (whooping cough) Measles Mumps Rubella (German measles) Hib Pneumococcus Hepatitis B Hepatitis A Polio Varicella In the first module, we talked about all the childhood diseases that vaccines prevent. Here they are again. Sometimes, two or more vaccines are combined in a single shot. {Note - in some areas, the speaker may not want to include hepatitis A.}

Vaccines that prevent disease
Diphtheria Tetanus (lockjaw) Pertussis (whooping cough) Measles Mumps Rubella (German measles) Hib Pneumococcus-PCV7 Hepatitis B Hepatitis A Polio-IPV Varicella (chickenpox) DTaP MMR The vaccine called DTaP protects against 3 diseases: diphtheria, tetanus, and pertussis. The vaccine called MMR also protects against 3 diseases: measles, mumps, and rubella. You might hear some vaccines called by different names. Pneumococcus vaccine is also called “Prevnar” because that’s its commercial name. Sometimes it’s called PCV, or PCV-7. Polio vaccine is called “IPV,” which is short for “Inactivated Polio Vaccine.” (“Inactivated” means that the polio virus is killed to make this vaccine.) “Varicella” is the medical name for chickenpox.

Recommended Childhood Immunization Schedule United States, 2002
range of recommended ages catch-up vaccination preadolescent assessment Age Vaccine 1 mo 2 mos 4 mos 6 mos 12 mos 15 mos 18 mos 24 mos 4-6 yrs 11-12 yrs 13-18 yrs Birth Hep B #1 only if mother HBsAg ( - ) Hepatitis B1 Hep B series Hep B #2 Hep B #3 Diphtheria, Tetanus, Pertussis2 DTaP DTaP DTaP DTaP DTaP Td Haemophilus influenzae Type b3 Hib Hib Hib Hib Inactivated Polio4 IPV IPV IPV IPV Measles, Mumps, Rubella5 MMR #1 MMR #2 MMR #2 Varicella6 Varicella Varicella Pneumococcal7 PCV PCV PCV PCV PCV PPV Vaccines below this line are for selected populations Hepatitis A8 Hepatitis A series Influenza9 Influenza (yearly) This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 1, 2001, for children through age 18 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible Indicates age groups that warrant special effort to administer those vaccines not previously given. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations.

Hepatitis B vaccine Dose #1 - Birth or up to 2 months
Dose #2 - 1 to 2 months Dose #3 - 6 to 18 months Catch up as soon as possible. The series never needs to be restarted when there has been a long time between doses. To review: Dose #1 is recommended at birth or up to 2 months of age. Dose #2 comes after that -- usually at 1 to 2 months of age. Dose #3 can be given from 6 to 18 months of age. The main thing is that all three doses are needed for full protection. Any child who didn’t get the full 3-dose series early in life should catch up as soon as possible. As with other vaccines, the hepatitis B vaccine series never needs to be restarted, even when there has been a long time between doses. The child should just get the doses missed.

range of recommended ages catch-up vaccination preadolescent assessment Age Vaccine 1 mo 2 mos 4 mos 6 mos 12 mos 15 mos 18 mos 24 mos 4-6 yrs 11-12 yrs 13-18 yrs Birth Hep B #1 only if mother HBsAg ( - ) Hepatitis B1 Hep B series Hep B #2 Hep B #3 Diphtheria, Tetanus, Pertussis2 DTaP DTaP DTaP DTaP DTaP Td Haemophilus influenzae Type b3 Hib Hib Hib Hib Inactivated Polio4 IPV IPV IPV IPV Measles, Mumps, Rubella5 MMR #1 MMR #2 MMR #2 Varicella6 Varicella Varicella Pneumococcal7 PCV PCV PCV PCV PCV PPV Vaccines below this line are for selected populations Hepatitis A8 Hepatitis A series Influenza9 Influenza (yearly) This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 1, 2001, for children through age 18 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible Indicates age groups that warrant special effort to administer those vaccines not previously given. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations.

DTaP DTaP stands for: “Diphtheria, Tetanus, & acellular Pertussis”
The first 4 doses are usually given at ages: Dose #1 - 2 months Dose #2 - 4 months Dose #3 - 6 months Dose # to 18 months (or 12 months) The first booster is usually given before school when the child is 4-6 years of age. Let’s review what we’ve just learned: [FACILITATOR: HIT DOWN ARROW] What does DTaP stand for? [HIT DOWN ARROW] Yes… Etc.

range of recommended ages catch-up vaccination preadolescent assessment Age Vaccine 1 mo 2 mos 4 mos 6 mos 12 mos 15 mos 18 mos 24 mos 4-6 yrs 11-12 yrs 13-18 yrs Birth Hep B #1 only if mother HBsAg ( - ) Hepatitis B1 Hep B series Hep B #2 Hep B #3 Diphtheria, Tetanus, Pertussis2 DTaP DTaP DTaP DTaP DTaP Td Haemophilus influenzae Type b3 Hib Hib Hib Hib Inactivated Polio4 IPV IPV IPV IPV Measles, Mumps, Rubella5 MMR #1 MMR #2 MMR #2 Varicella6 Varicella Varicella Pneumococcal7 PCV PCV PCV PCV PCV PPV Vaccines below this line are for selected populations Hepatitis A8 Hepatitis A series “So here we see it again on the table - DTaP at 2, 4, & 6 months…”} [HIT DOWN ARROW to highlight Hib vaccine] The next vaccine on the list is Hib (short for Haemophilus influenzae type b -- people sometimes called it “the meningitis vaccine”). It is usually given at 2, 4, and 6 months of age, with one booster after the first birthday. With one brand of this vaccine, the 6 month dose isn’t needed. Influenza9 Influenza (yearly) This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 1, 2001, for children through age 18 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible Indicates age groups that warrant special effort to administer those vaccines not previously given. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations.

range of recommended ages catch-up vaccination preadolescent assessment Age Vaccine 1 mo 2 mos 4 mos 6 mos 12 mos 15 mos 18 mos 24 mos 4-6 yrs 11-12 yrs 13-18 yrs Birth Hep B #1 only if mother HBsAg ( - ) Hepatitis B1 Hep B series Hep B #2 Hep B #3 Diphtheria, Tetanus, Pertussis2 DTaP DTaP DTaP DTaP DTaP Td Haemophilus influenzae Type b3 Hib Hib Hib Hib Inactivated Polio4 IPV IPV IPV IPV Measles, Mumps, Rubella5 MMR #1 MMR #2 MMR #2 Varicella6 Varicella Varicella Pneumococcal7 PCV PCV PCV PCV PCV PPV Vaccines below this line are for selected populations Hepatitis A8 Hepatitis A series The next vaccine is polio vaccine. It is called IPV for “inactivated polio vaccine.” Dose # 1 is at 2 months, dose #2 is at 4 months, then there is a lot of leeway about when to give dose #3. It is recommended any time between 6 and 18 months of age. Also a booster is recommended before a child starts school. Influenza9 Influenza (yearly) This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 1, 2001, for children through age 18 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible Indicates age groups that warrant special effort to administer those vaccines not previously given. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations.

range of recommended ages catch-up vaccination preadolescent assessment Age Vaccine 1 mo 2 mos 4 mos 6 mos 12 mos 15 mos 18 mos 24 mos 4-6 yrs 11-12 yrs 13-18 yrs Birth Hep B #1 only if mother HBsAg ( - ) Hepatitis B1 Hep B series Hep B #2 Hep B #3 Diphtheria, Tetanus, Pertussis2 DTaP DTaP DTaP DTaP DTaP Td Haemophilus influenzae Type b3 Hib Hib Hib Hib Inactivated Polio4 IPV IPV IPV IPV Measles, Mumps, Rubella5 MMR #1 MMR #2 MMR #2 Varicella6 Varicella Varicella Pneumococcal7 PCV PCV PCV PCV PCV PPV Vaccines below this line are for selected populations Hepatitis A8 Hepatitis A series MMR is easier to remember. One dose is given after the first birthday and a second dose is given before school entry, when the child is 4-6 years of age. That green bar at the end does NOT mean a third dose: it’s just there as a reminder that infants/children who haven’t had two doses should get caught up as soon as possible. Influenza9 Influenza (yearly) This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 1, 2001, for children through age 18 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible Indicates age groups that warrant special effort to administer those vaccines not previously given. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations.

range of recommended ages catch-up vaccination preadolescent assessment Age Vaccine 1 mo 2 mos 4 mos 6 mos 12 mos 15 mos 18 mos 24 mos 4-6 yrs 11-12 yrs 13-18 yrs Birth Hep B #1 only if mother HBsAg ( - ) Hepatitis B1 Hep B series Hep B #2 Hep B #3 Diphtheria, Tetanus, Pertussis2 DTaP DTaP DTaP DTaP DTaP Td Haemophilus influenzae Type b3 Hib Hib Hib Hib Inactivated Polio4 IPV IPV IPV IPV Measles, Mumps, Rubella5 MMR #1 MMR #2 MMR #2 Varicella6 Varicella Varicella Pneumococcal7 PCV PCV PCV PCV PCV PPV Vaccines below this line are for selected populations Hepatitis A8 Hepatitis A series Varicella vaccine is a lot like MMR. It is given on or after the first birthday. A second dose is not needed. Again, the green bar at the end is there as a reminder that infants/children who haven’t had varicella vaccine should get it as soon as possible. (Of course, if a child has had chickenpox, he or she won’t need the vaccine.) Influenza9 Influenza (yearly) This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 1, 2001, for children through age 18 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible Indicates age groups that warrant special effort to administer those vaccines not previously given. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations.

range of recommended ages catch-up vaccination preadolescent assessment Age Vaccine 1 mo 2 mos 4 mos 6 mos 12 mos 15 mos 18 mos 24 mos 4-6 yrs 11-12 yrs 13-18 yrs Birth Hep B #1 only if mother HBsAg ( - ) Hepatitis B1 Hep B series Hep B #2 Hep B #3 Diphtheria, Tetanus, Pertussis2 DTaP DTaP DTaP DTaP DTaP Td Haemophilus influenzae Type b3 Hib Hib Hib Hib Inactivated Polio4 IPV IPV IPV IPV Measles, Mumps, Rubella5 MMR #1 MMR #2 MMR #2 Varicella6 Varicella Varicella Pneumococcal7 PCV PCV PCV PCV PCV PPV Vaccines below this line are for selected populations Hepatitis A8 Hepatitis A series PCV -- the Pneumococcus vaccine -- is recommended at 2,4, and 6 months of age with a booster dose between 12 and 15 months of age. There are actually two pneumococcal vaccines. The other one is recommended for older children who have certain medical conditions (e.g., sickle cell disease or HIV infection) and some adults. This is the “PPV” shown in the yellow bar to the right. Influenza9 Influenza (yearly) This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 1, 2001, for children through age 18 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible Indicates age groups that warrant special effort to administer those vaccines not previously given. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations.

range of recommended ages catch-up vaccination preadolescent assessment Age Vaccine 1 mo 2 mos 4 mos 6 mos 12 mos 15 mos 18 mos 24 mos 4-6 yrs 11-12 yrs 13-18 yrs Birth Hep B #1 only if mother HBsAg ( - ) Hepatitis B1 Hep B series Hep B #2 Hep B #3 Diphtheria, Tetanus, Pertussis2 DTaP DTaP DTaP DTaP DTaP Td Haemophilus influenzae Type b3 Hib Hib Hib Hib Inactivated Polio4 IPV IPV IPV IPV Measles, Mumps, Rubella5 MMR #1 MMR #2 MMR #2 Varicella6 Varicella Varicella Pneumococcal7 PCV PCV PCV PCV PCV PPV Vaccines below this line are for selected populations Hepatitis A8 Hepatitis A series Hepatitis A vaccine is recommended for all children 2 years old or older who live in areas where hepatitis A virus is very common. Influenza vaccine (or “flu vaccine”) is recommended for all infants/children 6 months of age or older who are at risk for serious illness from influenza. For example, infants/children with asthma, heart defects, or diabetes are all prone to getting very sick from influenza. Healthy infants/children 6 months and older can also get flu vaccine. This vaccine is given every year in the fall. Influenza9 Influenza (yearly) This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 1, 2001, for children through age 18 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible Indicates age groups that warrant special effort to administer those vaccines not previously given. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations.

range of recommended ages catch-up vaccination preadolescent assessment Age Vaccine 1 mo 2 mos 4 mos 6 mos 12 mos 15 mos 18 mos 24 mos 4-6 yrs 11-12 yrs 13-18 yrs Birth Hep B #1 only if mother HBsAg ( - ) Hepatitis B1 Hep B series Hep B #2 Hep B #3 Diphtheria, Tetanus, Pertussis2 DTaP DTaP DTaP DTaP DTaP Td Haemophilus influenzae Type b3 Hib Hib Hib Hib Inactivated Polio4 IPV IPV IPV IPV Measles, Mumps, Rubella5 MMR #1 MMR #2 MMR #2 Varicella6 Varicella Varicella Pneumococcal7 PCV PCV PCV PCV PCV PPV Vaccines below this line are for selected populations Hepatitis A8 Hepatitis A series Now, let’s take a look at a child of six months of age. Which vaccines should the child’s health care provider be thinking about (ASK THE GROUP TO RESPOND) [HIT DOWN ARROW to highlight 6-month vaccines] Hepatitis B DTaP Hib IPV PCV (and possibly influenza in the fall) You may think, “Is this too many vaccines to give a baby?” In our NEXT module, we’ll address this and other common questions of vaccine safety. Before we go on, what questions do you have about the immunization schedule? [Note: Students might, correctly, point out that two of these vaccines (hepatitis B and IPV – three if you count influenza) have a range of ages at which they can be given, so it isn’t necessary to give all 5 vaccines exactly at 6 months.] Influenza9 Influenza (yearly) This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 1, 2001, for children through age 18 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible Indicates age groups that warrant special effort to administer those vaccines not previously given. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations.

Module 3 Facts about Vaccines & Answers to Common Vaccine Questions
This module is designed to help you know some basic facts about vaccines and the answers to common questions that people sometimes have about vaccines. WIC’s role is not to be the experts on vaccines. You certainly don't have to know all the answers. This information is provided to help answer questions you may have yourself or that WIC parents may have.

Everyone should know key vaccine information!
In order to be an effective promoter of immunizations, it is important to learn some basic facts.

parents can protect their children.
Vaccines are one of the most important ways to protect children! There are 5 chief concepts that everyone should know about vaccines. The first concept is the single most important message. Vaccines are one of the most important ways parents can protect their children. Like seat belts and clean drinking water, vaccines protect infants/children from serious danger.

Vaccines are safe Many billion vaccinations have been given safely
Every vaccine that is made meets strict safety requirements. The second concept is that vaccines are safe. Immunizations are extremely safe thanks to advances in medical research and ongoing review by doctors, researchers, and public health officials. Many billion vaccinations have been given safely over the span of decades in the US -- not to mention worldwide. A system of safeguards exists to ensure the safety of every dose of vaccine. The Food and Drug Administration has to approve the safety of every vaccine before it is licensed. Than it monitors production of vaccines to make sure strict safety requirements are met.

Disease risks outweigh Vaccine risks
Vaccines have common side effects (such as fever or soreness at the injection site). These are mild. Vaccines can have more severe side effects (such as an allergic reaction). These are rare. The potential harm from the diseases far outweighs the potential for vaccine side effects The third concept is that the risk of complications from the diseases far outweighs the potential for vaccine side effects. Despite the fact that vaccines are very safe, it is important to remember that nothing is 100% safe, and this includes vaccines. -Vaccines do have several common side effect, such as fever or soreness where the shot is given, these are mild. -Vaccines can also have more severe side effects, such as allergic reactions, but these are rare. -Despite the slight risk from vaccines, a person who gets a disease such as measles or tetanus or hepatitis B is at far greater risk for serious complications than a person who gets the vaccine. Getting a vaccine is much safer than getting a disease.

Waiting can be Risky Vaccinate early!
You never know when an exposure or outbreak may occur Once an outbreak has been identified, it may be too late The fourth concept to know is that waiting to vaccinate has risks. -Infants and young children are particularly vulnerable to infectious diseases so they should be vaccinated as soon as possible. -Parents should follow the schedule and vaccinate at the earliest recommended age. -You never know when an outbreak will occur in this country…these diseases are never more than a plane ride away. -If there is an outbreak, it may be too late. Many children may be exposed before we are even aware an outbreak has started. Vaccination of children after they are exposed to disease will often not protect them.

Not vaccinating is risky
The decision not to vaccinate is a choice to remain at risk for disease Finally, it is important to know that the decision not to vaccinate is a choice to remain at risk for diseases. If a child is exposed to a disease like measles, pertussis, or chickenpox – vaccination is the only thing standing between that child and a potentially serious illness. Without vaccination, there is nothing standing between the child and illness. Many diseases that vaccines will prevent have no treatment available if the child gets the disease. Parents may have heard news stories or seen websites dealing with the safety of vaccines; and they might have specific concerns about vaccines. The next two slides deal with two of the most common.

Do vaccines overload the immune system?
Infants/children are exposed to germs every day. The number of “germs” they get from vaccines is small compared with what they get from their daily environment. It’s possible for a child to receive as many as 7 injections during a single visit. Understandably, this makes some parents nervous, fearing that getting all these vaccines at the same time is dangerous. infants/children are exposed to a barrage of germs every day. In addition to bacteria introduced to the body from food, and those that live in the mouth and nose of everyone, even a minor illness like “strep throat” can expose a child to different germs. The number of germ-like particles in a vaccine pales in comparison. The immune system can easily handle the slight additional load presented by vaccines.

Does MMR vaccine cause autism?
% of Children receiving MMR vaccine; Caseload of autistic children by year of birth, California, The apparent rise in autism didn’t happen with the increase of MMR. Some people may have heard that the MMR vaccine causes autism. This is in the news a lot lately. First, a number of well-controlled studies have shown no evidence that MMR (measles, mumps, and rubella) vaccine causes autism. Still, some continue to point out that autism has increased dramatically in recent years, and believe that increases in children getting MMR vaccine is the cause. If this were true, we would expect the number of children getting vaccinated to have risen at the same rate as the number of cases of autism. But California conducted a study that showed this did not happen. You’ll notice on the graph on this slide that while the number of children with autism rose by about 500% between 1980 and 1994 (the bottom curve), the percentage of children getting MMR vaccine during the same time period increased only slightly. There may be a number of explanations for the rise in autism (for instance, it may simply be getting diagnosed more often than it used to) – but so far there is no evidence to suggest that immunizations are one of them. Dales, et al, JAMA, Vol 285, No. 9, March 2001

Some parents may have questions about vaccines
Parents with questions should be referred to the child’s physician or an immunization clinic.

Module 4 WIC’s Role: Helping Kids Stay Healthy
Did you know that… Many low-income infants/children don’t receive their immunizations on time or at all? In this module, we will discuss why WIC is important in the effort to get infants/children immunized and how WIC can help. Low-income infants/children are less likely to receive shots: Immunizing infants/children against certain diseases is one important way to help them stay healthy. Unfortunately, many low-income children don’t receive their immunizations on time or at all. That means that millions of infants/children each year run the risk of developing a fatal or crippling disease that could have been prevented through immunization.

WIC’s Role: Helping Kids Stay Healthy
WIC is an adjunct to health care WIC supports immunization services WIC refers and educates WIC helps parents understand their child’s need for immunizations WIC shares information on where infants/children can get their immunizations Adjunct to health care: Congress set up the WIC Program to “serve as an adjunct to good health care, during critical times of growth and development, to prevent the occurrence of health problems…and improve the health status” of WIC participants. What exactly does adjunct mean? Adjunct means: “something joined or added to another thing but not essentially a part of it.” WIC’s mission is to be a partner with other services that are key to childhood and family well-being, such as immunization. As an adjunct to services that provide immunizations, the WIC Program’s role is to find out about a child’s need for immunizations and share that information with parents, including when, how, why, and where to get a child immunized. Why is WIC so important to this effort? WIC serves almost half of all the infants born in the United States. That means that WIC can help millions of low-income infants/children get immunized by referring them to immunization services and educating parents about the importance of keeping infants/children up to date with shots and regular medical care.

WIC’s Role: Helping Kids Stay Healthy
Infants/children who are up to date on their shots are less likely to suffer from other health problems like anemia and lead toxicity Good nutrition and immunizations go hand in hand to help WIC children stay healthy (Instructor: Read Slide)

Breastfeeding and Immunizations
Some interesting facts: Breastfeeding: babies’ “first immunization” Mothers who intend to breastfeed are more likely to get infant immunized Breastfed babies have better responses to vaccines Breastfeeding babies handle shots better while breastfeeding (less pain) Let’s take a look at the relationship between breastfeeding and immunizations. --Breastfeeding is sometimes referred to as baby’s “first immunization” because it protects newborns against infections by strengthening their immune systems. --Mothers who intend to breastfeed are more likely to get infant immunized --Breastfed babies have better responses to vaccines Did you know that some doctors advise mothers to breastfeed their babies at the time of a shot? Studies have shown that breastfeeding can act as a pain reliever for shots.

WIC helps babies get their first immunization – breastfeeding WIC can help babies further strengthen their immunity against disease by helping them get properly vaccinated read slide

WIC helps mom breastfeed. WIC helps kids get immunized. What a great combination! Read slide

Module 5 New WIC Immunization Screening and Referral Policy
In this module you will learn about WIC’s new immunization screening and referral policy. The new policy will help improve immunization rates of low-income infants/children.

Overview of December 2000 White House Memorandum
Low-income infants/children are not as well immunized as higher income infants/children WIC has access to the largest number of low-income infants/children and holds great potential to improve immunization rates Immunization screening and referral should become a standard part of WIC certification. Screening should be conducted using a documented record of immunizations. WIC benefits are never to be denied for lack of immunization records or shots. In December 2000 a White House Memorandum was issued. It cited the importance of immunization in preventing vaccine-preventable diseases and the need for WIC and Immunization programs to focus efforts to increase immunization rates among infants/children at risk. The memorandum called for the development of a standardized procedure in WIC to determine the immunization status of infants/children and refer those in need of immunizations to appropriate health care providers. The standardized procedure requires that WIC screen a child’s immunization status using a documented immunization history. This allows WIC to conduct more accurate immunization screening for referral. The White House Memorandum also directed that immunization screening and referral procedures should never be used as a condition of eligibility for WIC or the receipt of WIC benefits.

Overview of USDA Policy Memorandum (2001)
Outlined a minimum immunization screening and referral requirement in WIC To be implemented in all WIC agencies by March 1, 2003 To implement the directives of the White House Memorandum, USDA issued a policy memorandum in August The USDA policy memorandum outlines a minimum WIC requirement for immunization screening and referral. As you will see in the coming slides, WIC’s new minimum requirement allows for an accurate, efficient and appropriate screening and referral process in WIC.

WIC Minimum Requirement for Immunization Screening and Referral
Advise parents of any infant or child under two years of age to bring immunization records to certification Screen using a documented immunization record, rather than parent’s memory or verbal assurance Determine the child’s age, then count the number of doses of DTaP vaccines the child has received Provide information on recommended immunization schedule Provide referral if needed Encourage parent to bring the immunization record to next certification visit This is an overview of the steps involved in WIC’s minimum requirement for immunization screening and referral. Note that we will be using the number of DTaP shots a child has received as an indicator of the child’s status with all immunizations.

Diagram of the WIC Minimum Requirement
For Immunization Screening and Referral This slide walks you through the steps you need to take to screen and refer infants and children under two years of age for immunizations at WIC certifications. We will go through them now to give you an idea of what to expect. We will then go through the steps in more detail in the upcoming slides. (Facilitator may want to use pointer to follow diagram.) First, the infant/child comes to the clinic for a certification visit. Does the parent have a documented immunization record with them? If no, provide a handout about the immunization schedule. Encourage the parent to talk to the child’s doctor and/or make referral to an immunization clinic. Tell parent you will be asking for a record when the child is recertified. If the parent does bring an immunization record to the WIC visit, count the number of DTaPs the child has received and determine if it is the right number for the age of the infant/child. If it is not, advise the parent that it appears the baby is in need of shots. Make a referral to the baby’s doctor and/or to an immunization clinic. Tell the parent you will be asking for a record when the child is recertified. If the child’s shot record shows that the child has received the expected number of DTaPs for the his age, explain to the parent that the child seems to be getting the shots he needs. Congratulate the parent. Tell the parent WIC will be asking for the shot record at each certification.

Module 6 Using Documented Immunization Records for Screening and Referral in WIC
As you have seen, the new requirement in WIC is to use a documented immunization record to screen for immunizations. In this module, you will learn the importance of using documented immunization records to screen for shots.

What is a documented immunization record?
It is a record that has details of each immunization dose given Acceptable records are: A personal immunization record carried by the parent that has been prepared by the provider A printout from an official source such as a registry, the health department, doctor’s office or clinic An official immunization record will show documentation of each vaccine dose, date, and information about the vaccine and provider who gives the vaccine. The parent or guardian may carry the infant/child’s personal immunization record that the provider’s office staff has prepared. This record can be used for official documentation. Some areas have computerized records from a registry, the provider practice, or some other type of automated data system. When a computerized system is in place, these records are also official and may be used.

Why is it important to use a documented immunization record?
A documented record of shots is more accurate than the parent’s memory. When asked, parents typically overestimate their child’s immunization status Many times parents may believe that their infants/children are up to date because they’ve taken the child to the doctor, but a check of the immunization record shows that the child is behind on immunizations. In WIC, we can no longer simply ask the parent if the child is up to date on shots. Asking the parent to remember, is not an accurate way to screen for shots. WIC must screen for immunizations using a documented immunization record. A documented record of shots is more current and accurate than a parent's memory

Advise parents to bring immunization records
Make certification appointment Instruct parent/caregiver to bring the immunization record Explain importance Explain to the parent the importance that WIC places on making sure that children are up to date on immunizations. Instruct parent to bring the immunization record to the appointment.

WIC benefits are not tied to immunization records
Reassure parents that immunization records are requested as part of the WIC certification and health screening process, but are not required to obtain WIC benefits

Sample Script “Please bring Miguel’s shot record to your
appointment. Immunization records are not required to obtain WIC benefits, but they are an important part of the health screening WIC provides. We want to help you make sure your child is up to date on shots.” This is an example of what might be said to a parent at the time the WIC certification appointment is established.

Help Parents Remember to Bring Record
Helpful Tips: Phone call indicating time of appointment and reminder to bring the shot record. Postcard indicating time of appointment and reminder to bring the shot record. Promotional posters in the waiting room reminding parents to bring shot record to WIC appointments. Reminder phone calls, postcards mailed to the home, and posters in the waiting room can be used to help to remind parents to bring immunization records to WIC appointments.

Thank parent each time they bring record!
Be sure to thank the parent each time they bring immunization records to WIC appointments. It’s important to let them know that WIC appreciates their effort and that is it worthwhile for them to bring the record.

Module 7 Counting DTaP Vaccinations
What are the advantages of counting DTaP doses? How do I count DTaP doses? WIC’s new minimum screening and referral policy requires WIC to screen for immunizations by counting doses of DTaP vaccine. This module will help you understand (1) the advantages of counting DTaP doses and (2) how to count number of doses of DTaP vaccines a child has received in relation to age.

What is a DTaP vaccine? The vaccine contains a combination of:
D = Diphtheria Toxoid T = Tetanus (Lockjaw) Toxoid aP = Pertussis Vaccine (Whooping cough) You will remember from our review of the recommended childhood immunization schedule that DTaP is a combination of three vaccines, Diphtheria, Tetanus, and Pertussis. (The small “a” stands for “acellular” and describes the type of pertussis vaccine.) In order to provide adequate protection, the infant/child must receive several doses of the DTaP vaccine at various ages. Four of these vaccine doses should be given before the child is two years of age. The recommended ages for these four doses are two months, four months, six months, and sometime between twelve to eighteen months of age.

Why was DTaP selected? DTaP was selected to screen the
immunization status of WIC infants/children under two years of age because: It is a good reflection of the up-to-date status of the child’s other immunizations It is easier and quicker than counting the doses of all 11 vaccines DTaP is a well known vaccine that has been given to infants/children for many years. It is also given at the same time as several other vaccines. WIC has agreed to help the immunization program by counting DTaP doses according to the child’s age. DTaP was selected as the vaccine to screen WIC infants/children because: A study of WIC infants/children demonstrated that it is reasonable to assume that an child who has received the proper number of DTaP doses has also received the proper number of other vaccine doses. Counting the doses of DTaP is much easier and quicker than counting the doses of all 11 (or possibly 13) childhood vaccines

Minimum Number of Doses
Up-To-Date Means…. DTaP Vaccine By Age Minimum Number of Doses Birth through 1month 3 months 1 5 months 2 7 months 3 19 months 4 If an infant/child is up to date on immunizations, you will see that by three months of age the infant/child will have received one dose of DTaP, by 5 months of age two doses, by 7 months of age, three doses, and by 19 months of age, four doses. Sometimes an infant/child gets behind on their immunization schedule and then their immunizations status is a little harder to evaluate. This will be covered in more detail later, and you will have a chance to practice.

Personal / Hand Held Records
Here are some examples of personal immunization records you may see. Although they may look different at first glance, the information they contain is very similar. On each immunization record there is at least one section where doctors or health care providers record the doses of DTaP vaccine given to an infant or child. The section of the record will be labeled DTaP, DTP, DT, or Td. There may be a section on the record labeled DTaP/Hib.

Variations on DTaP Vaccine
DTaP (Diphtheria, Tetanus, acellular Pertussis) DTP (Diphtheria, Tetanus, Pertussis) DT (Pediatric Diphtheria & Tetanus) DTaP/Hib (Diphtheria, Tetanus, acellular Pertussis & Hib) Td (Adult Tetanus & Diphtheria) As I said, a vaccination record might contain several different designations for vaccines containing tetanus, diphtheria, and pertussis. DTaP is the most common vaccine. As we’ve said before, it stands for Diphtheria, Tetanus, and acellular Pertussis vaccines. Some records might say DTP (without the small “a”). This is an older vaccine that is not used any more, but it might still be shown on the record. For our purposes, DTaP and DTP are the same thing. Doses of DTP should be counted. DT is a vaccine that contains only diphtheria and tetanus, but no pertussis vaccine. It is for children who should not get pertussis vaccine (for example, because of an allergy or previous reaction). It, too, should be considered the equivalent of DTaP for our purposes. DT doses should be counted. DTaP/Hib contains DTaP vaccine AND Hib (Haemophilus influenzae type b) vaccine in the same needle. Doses of DTaP/Hib should be counted If a record shows that a child got a combination of these vaccines (for instance DTaP at 2 months, and DT at 4 months and 6 months), count them all. Td also contains diphtheria and tetanus vaccines, but is formulated for older children (over 7 years of age) and adults. Infants, and children under 7 should not get this vaccine, so you don’t need to be concerned with it.

Close up View of an Infant/Child’s Record
Vaccine Type Mo/Day/Yr of dose Health Provider Date Next dose due DTaP/DTP DT/Td Diphtheria Tetanus Pertussis (Specify Type) 1 Tripedia 9/3/02 A.Coulter, MD/Kids Clinic 11/3/02 2Tripedia 11/14/02 01/14/03 3 Infanrix 01/21/03 10/21/03 4 Daptacel Cordova Co. H.D., AZ 7/3/06 5 This is the DTaP section of a typical immunization record. This is the only part of the record you will need to learn to read. You will see more examples and have a chance to practice screening an immunization record by counting DTaP doses in the upcoming practice session.

Module 8 Talking to parents about their child’s immunization status
When you screen a child’s immunization record you will be able to draw some conclusions about his or her immunization status – namely whether or not the child is up-to-date with his or her shots. By the end of this module you will understand the appropriate information to provide to parents regarding their child’s immunization status. Later you will have a chance to practice providing this information to parents.

Congratulate Parent Sample Script
“You’re doing a great job of protecting your [baby/child] against very serious diseases like whooping cough. Please remember that there may be other vaccines, besides the one protecting him/her against Whooping Cough that your [baby/child] may not yet have received. Congratulations! Keep up the good work and remember to get each immunization on time.” If screening the record shows that the infant or child is up-to-date on the number of DTaP doses received, be sure to congratulate the parent and encourage them to keep up the good work.

Urgency Message Sample script
“Your [baby/child] has not received all the shots [he/she] needs to be protected from Whooping Cough and other very serious, and sometimes deadly diseases. You need to contact your doctor right away to schedule an appointment for immunizations.” If screening the record shows that the infant or child is NOT up-to-date on the number of DTaP doses received, try to be supportive when talking to the parent so that they know that you want to help them protect their child from diseases. WIC can make an impact by taking this time to educate, support, and provide a referral to the doctor or immunization clinic.

Providing Education Provide copy of recommended immunization schedule
Provide other educational materials if desired If the child is under-immunized or if the parent did not bring a documented immunization record, provide information on the recommended immunization schedule appropriate to the current age of the infant/child. This can be easily accomplished by providing the parent with a copy of the recommended childhood immunization schedule. Other educational materials such as facts sheets and brochures can also be provided if desired.

Module 9 Making Effective Referrals
Referring WIC participants for Immunizations The purpose of this module is to discuss effective referrals for WIC infants and children who need immunization services.

Barriers to Childhood Immunizations
No health care provider Cost (money) Transportation (no car or bus) Waiting time for appointment Waiting time in office Not knowing what shots are due or when they are due Let’s first take a look at a few of the things that can cause infants/children to get behind on their immunizations or not get them at all. A barrier is anything that prevents a child from being immunized. Low income families are more likely to experience more than one barrier, making it that much harder for their infants/children to receive their immunizations on time. Some common barriers are described in this slide. Can you think of other barriers that may prevent a child from being immunized? WIC, through an effective referral system, can help minimize the impact of these barriers by coordinating with local Immunization programs and providers. For example, where possible, co-scheduling immunizations with WIC appointments can help save time for the clinic and the client.

Effective referrals Identify providers who offer immunizations
Establish relationships with providers Help clients choose a provider Helping parents to get their child immunized starts with making the best referral possible. This module will walk you through some suggested ways to refer parents to immunization services so that their infants/children can get immunized on time.

Identify providers who offer immunizations
With assistance from Immunization program, develop list of: Private providers (pediatricians/family practice doctors) Walk-in clinics Appointment only clinics Mobile vans On-site immunization services Your local Immunization program can provide information on local or on-site immunization service locations, phone numbers, times, etc.

Medical Home Why important? Comprehensive care in one location
Child and family develop relationship with physician Better follow-up In helping WIC parents choose immunization providers, it is important to discuss the advantage to clients of having a specific primary care provider in order to give the child what we call a “medical home.” Getting immunizations should be a part of well-baby care. It is important for every baby to have a health care provider to go to for well care, as well as sick care. WIC can promote that all infants/children attain a “medical home” in order to help infants/children obtain comprehensive health care that includes all aspects of their needs in one location. A medical home provides the opportunity for a physician to develop a relationship of mutual responsibility and trust with the child and family. The medical home can be a pediatrician or family physician’s office. If referral to a medical home is not possible, referral should be made to an immunization program, clinic or other service.

Vaccines for Children (VFC) Program
Provides no-cost vaccines for children if they are at least one of the following: Medicaid eligible Without health insurance or under-insured American Indian or Alaska Native Allows infants/children to receive immunizations at their medical home In developing your list of immunization referral sources, look for providers who participate in the Vaccines for Children, or VFC, program. The VFC program is a federal program that provides eligible children all recommended vaccines at no cost. Most pediatricians and family doctors take part in the VFC Program. Your local Immunization program should have information on which providers participate in VFC and other no-cost or low-cost immunization programs.

Establish Relationships
Establish relationships with local providers, especially office staff Discuss appointment procedures and obtain other necessary information Establish relationships with key providers in your community. Especially get to know the office staff. They can be your best sources of information. When possible, find out the provider’s appointment procedures, including procedures for walk-in appointments.

Be Specific Provide address, phone number, days/hours open
Tell parent what to expect requires well child exam? has bilingual staff? appointment only? Provide the parent with specific information whenever possible, such as address, phone number and walk-in clinic days of immunization services. Provide as much information as you can to help the parent know what to expect at that clinic, e.g. does the provider require a well child exam prior to giving immunizations, does the provider have bilingual staff, does the provider only see patients with appointments, etc.

Follow-up with WIC parent if possible
Ask if child received shots If no, find out if there was a barrier. Ask for assistance from immunization staff at local health department As much as possible, follow-up with the parent at the next WIC appointment or certification. Ask the parent if the child was able to get immunized. If the child didn’t get immunized, try to find out why. If the parent had a problem getting the child immunized, offer other resources such as public health nurses and/or immunization staff at local health department to answer parent’s questions, make appointments, etc.

Help problem-solve Share what clients are telling you about barriers encountered Let the immunization program know about the barriers that WIC clients are facing. Help problem-solve by talking with other WIC staff. Are you hearing about barriers at certain clinics? You may want to inform your local Immunization program staff about these problems-–it is the their job to know where barriers exist and to try to minimize them. You may also consider informing the provider. You may decide not to refer WIC clients to providers who do not provide good service.

Diagram of the WIC Minimum Requirement
For Immunization Screening and Referral You’ve learned a lot today. Before we practice some of these, let’s quickly review. This slide walks you through the steps you need to take to screen and refer infants and children under two years of age for immunizations at WIC certifications. (Instructor may want to use pointer to follow diagram.) First, the child comes to the clinic for a certification visit. Ask: does the parent have a documented immunization record with them? If no, provide a handout about the immunization schedule. Encourage the parent to talk to the child’s doctor and/or make referral to an immunization clinic. Tell parent you will be asking for a record when the child is recertified. If the parent has brought an immunization record to the WIC visit, count the number of DTaP doses the child has received and determine if it is the right number for the age of the infant/child, according to the table we looked at earlier. If it is not, advise the parent that it appears the baby is in need of shots. Make a referral to the baby’s doctor and/or to an immunization clinic. Tell the parent you will be asking for a record when the child is recertified. If the child’s shot record shows that the child has received the expected number of DTaP doses for the his age, explain to the parent that the child seems to be getting the shots he needs. Congratulate the parent. Tell the parent WIC will be asking for the shot record at each certification.

Module 10 Hands-On Practice
Screening Immunization Records and Comparing to the Recommended DTaP Schedule In this module, you will practice screening immunization records and counting the number of DTaP doses.

Hands-On Practice During the practice use the Easy IZ Tool or an Immunization Schedule Compare an immunization record to the recommended Easy IZ Tool or schedule Determine if the infant/child is likely to be underimmunized. Now, we will practice screening records.

Easy IZ Tool 1. Ask for the infant/child’s immunization record.
2. What is the age of the infant/child in months? 3. Count the number of entries in the DTaP, DTP, DT and DTaP/Hib sections on the infant/child’s immunization record. 4. Look at the DTaP doses column of the Easy IZ tool 5. Does the infant/child have all of the doses due now for his or her age? 6. Look at the Action column and follow the actions described on the back side of the form. You will have your own copy of the Easy IZ Tool. It has been adapted from a tool that is used in California WIC immunization screening and it meets the minimum WIC requirement for immunization screening. To begin the practice exercise or to do an actual screening, you must first ask the parent for the infant/child’s immunization record. Remember, it may be hand written or a computer document as long as it was prepared by the provider. You will see that the tool provides a continuous flow of age so that you will know which rows to use to screen an infant/child of any age up to two years. The age of the infant/child refers to the age all the way to the end of the month. For example 2-3 months means all the way to the end of 3 months up to the time the infant/child becomes 4 months of age. Count the number of doses of DTaP, DTP, DT and DTaP/Hib on the record. Look at the Easy IZ tool to match the infant/child’s age and number of doses. Is the infant/child due any doses now? Follow the row to the Action column and follow the actions recommended. The back of your tool describes the actions to take.

Back of Easy IZ Tool Urgency Message Congratulate Parent
Refer for Immunizations Remind parent to bring immunization record to WIC visits Provide immunization schedule to parent The “Urgency Message” suggests what you can say to the parent when the infant/child’s immunization record indicates they need immunizations. It is important that they receive education on the importance of immunizations to protect their infant/child. When immunization screening indicates the infant/child has no immunizations due, congratulate the parent on helping to protect their infant/child from unnecessary diseases and encourage them to continue with the immunization schedule. Some parents may not have an immunization provider for their infant/child and they may not know where to go to get the needed care. Provide a list of local physician practices and encourage the parent to find one. Of refer to an immunization clinic or other immunization service. Remind the parent to bring the infant/child’s record to WIC visits. Explain that WIC can help the parents keep their baby protected from diseases by screening the immunization record. The parent should be provided a copy of the immunization schedule to take home.

Example One of an Infant/Child’s Record
Note to Graphics: We have a shot record for you to scan Here is an example of an immunization record. Look for one or more sections that pertain to DTaP vaccine. Did you find the DTaP sections?

#1 - Close up view of Infant/Child’s record
DTaP DT DTP # Mo Day Yr Name of provider or Health Department Date Next dose due 1 2 3 4 5 Note to Graphics: We want to hand write on this record We may also have an example of a printout of a shot record too. This is a close up view of the DTaP section of the immunization record. Remember, before you can screen this record you need to know the exact age of the infant or child in months. Suppose the infant is 20 months of age. Is he or she up-to-date? Suppose the infant is 8 months of age. Is he or she up-to-date?

Example Two of an Infant/Child’s Record
Note to Graphics: We have a sample record to scan Here is another example of an immunization record. Look for one or more sections that pertain to DTaP vaccine. Did you find the DTaP sections?

#2 - Close up view of Infant/Child’s record
Vaccine Type Mo/Day/Yr of dose Health Provider Date Next dose due DTaP/DTP DT/Td Diphtheria Tetanus Pertussis (Specify Type) 1 2 3 4 5 Note to Graphics: We want to hand write on this record This is a close up view of the DTaP section of that immunization record. Again, before you are able to screen this record you will need to know the exact age of the infant or child in months. If this infant were 1.5 months of age, would he or she be up-to-date? If this infant were 3 months of age, would he or she be up-to-date? If this infant were 4 months of age would he or she be up-to-date?

Module 11 Hands-On Practice
“What To Do When…” Situations and Possible Responses Naturally, we don’t expect every record or every screening situation to be exactly alike. In this module, we will look at several situations that may arise, and some possible responses to them. Instructor: You may wish to divide the audience into small groups and assign several “situations” to each group for review and discussion.

What To Do When… Parent forgets to bring record
Educate about importance Encourage to bring next time Provide immunization schedule Provide referral These next four slides involve situations where the parent/caretaker does not bring an immunization record to WIC certification. Situation: Parent/caregiver forgot to bring record. Possible Response: Discuss with the parent/caregiver the importance that WIC places on making sure that infants/children are up to date on immunizations. Encourage her to bring the record next time. Provide information on the recommended immunization schedule appropriate to the current age of the child. Provide referral for immunization services.

When parent forgets to bring record
Sample Script “The WIC program is required to screen immunization records for all infants/children under age two at WIC certifications. Vaccines can help prevent serious diseases. We want to make sure your child is up to date. Please bring your child’s shot record to your next WIC appointment.” Remember, even though WIC is required to screen immunization records when available, immunization records and/or an infant/child’s immunization status are in no way tied to the receipt of WIC benefits.

Important Reminder WIC benefits are never to be denied for lack of immunization records or shots.

What To Do When… Parent cannot find record
Educate about importance Encourage parent to talk to provider Provide immunization schedule Provide referral Situation: Parent cannot find record. This situation is likely to occur fairly often. Possible Response: Discuss with the parent/caregiver the importance that WIC places on making sure that infants/children are up to date on immunizations. Encourage her to talk to her provider about getting a new record. Provide information on the recommended immunization schedule appropriate to the current age of the child. Provide referral for immunization services, preferably to medical home.

Sample Script “It is important to have a personal record of your child's vaccinations. If you don't have a record, ask your child's health care provider to give you one. Bring this record with you every time you seek medical care for your child. Make sure your health care provider records all your child's vaccinations on the record. Your child will need it to enter daycare, kindergarten, junior high, etc.” This is an example of what you might say to a parent who doesn’t have or can’t find the child’s immunization record. The last sentence is important. If parents don’t have a valid immunization record when their child enters school, the child might have to repeat shots he/she has already taken.

What To Do When… Parent skips WIC appointment because of no IZ record
Encourage parent to always come to her scheduled appointments even if she can’t locate the immunization record. Assure her that WIC benefits will never be denied for lack of immunization records. Situation: A parent informs you that she skipped her last WIC appointment because she couldn’t find her child’s immunization record. She believes she cannot receive WIC benefits unless she brings in an immunization record. Possible response: Assure parent that WIC benefits are not tied to the review of immunization records and that she should always come in for her scheduled WIC appointment. However, discuss with her the importance that WIC places on making sure that infants/children are up to date on immunizations. Provide information on the recommended immunization schedule appropriate to the current age of the child. Provide referral for immunization services, preferably to the medical home.

What To Do When… Parent brings multiple records
Encourage her to talk to her provider about consolidating the records onto one. Provide referral Situation: In the situation, the parent might bring in five different records for the same child. Or a parent brings in multiple records with different names, but assures you they are for the same child. Possible Response: Encourage parent to talk to her provider about consolidating the records onto one. Provide a referral, preferably to medical home.

What To Do When… Record lists incomplete dates
Screen record for appropriate number of DTaPs Encourage parent to review record with health care provider This next group of scenarios involves hard-to-read immunization records. Situation: The immunization record lists different immunizations, but the dates are incomplete, i.e., month and year only, but no day. Possible response: Screen the record for the appropriate number of DTaPs. You need not be concerned about dates.

What To Do When… Entries are hard to read
Encourage parent to talk to provider Do not screen record Make referral Situation: The vaccines listed on the immunization record are hard to read or do not correspond to any you have ever seen before. Possible response: Encourage the parent to talk to her provider and explain that the record is hard to read. Do not screen the record because it is too easy to make mistakes. Make a referral to immunization services, preferably the child’s medical home.

What To Do When… Parent does not want WIC to screen child’s record
Educate about importance Provide referral Provide appropriate materials Situation: The parent does not want WIC to screen her child’s records. Possible response: As with any WIC service, the client has a right to decline. Try to find out why the parent does not want WIC to screen the child’s records. Some parents may have concerns about vaccine safety, or have religious or other objections to immunizations, or might be embarrassed at having an incomplete record or that the child is not up-to-date. Discuss with her the importance that WIC places on making sure that infants/children are up to date on immunizations. Reassure her that an incomplete record won’t jeopardize her WIC services, and that your purpose in screening is only to help her protect her child from disease. Provide information on the recommended immunization schedule appropriate to the current age of the child. Provide referral for immunization services, preferably to the medical home. Provide materials, if available, on vaccine safety.

What To Do When… Records are from another country
Encourage parent to talk to child’s health care provider. Do not screen record if hard to interpret. Provide referral. Situation: The record is from another country and in another language. Possible response: Thank the parent for bringing in the child’s records. Encourage parent to talk to her health care provider to see about getting the record translated and catching up if they are behind on any vaccines. This is especially important because studies show that foreign-born infants/children in the United States are less likely than U.S.-born infants/children to receive all their needed doses of vaccines. Provide referral for immunization services, preferably to the medical home. Contact staff of local Immunization program for assistance.

Congratulations! You’ve completed the immunization screening and referral training.

Thank you for all you do for WIC participants
We appreciate your hard work and dedication to the infants and young children served by WIC. Your efforts will help improve immunization rates and keep kids healthy.

WIC Immunization Screening and Referral

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WIC Immunization Screening and Referral

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